This document discusses motor rehabilitation after acute stroke. It notes that the majority of neurological recovery occurs within the first 3 months after stroke, but can continue for up to 1 year. Motor rehabilitation aims to reacquire lost movement skills through meaningful, repetitive, intensive, task-specific practice in an enriched environment. Current treatment methods discussed include constraint-induced movement therapy, treadmill training, robotic training, electrical stimulation, noninvasive brain stimulation, mirror therapy, and selective serotonin reuptake inhibitors.

1. Motor Rehabilitation After
Acute Stroke
Dr. Sunil Kumar Sharma
Senior Resident
Dept. of Neurology
GMC Kota

2. Definition
 From Latin “ habilitas “ – to make able
 Literal translation – “ to make able
again ”
 The process of helping a person to
achieve the highest level of
functioning, independence and quality
of life

3.  According to the WHO, 15 million
people suffer stroke worldwide each
year. Of these, 5 million die and
another 5 million are permanently
disabled.
 A number of neurological functions are
impaired by stroke, the most common
of which is motor disability
contralateral to the stroke lesion side

4. Neurological Recovery
 Majority of neurological recovery in
first 3 months
 5% of patients continue to show
recovery for up to 1 year
 Return of motor power not
synonymous with recovery of function

5. Neurological Recovery
 Improvement in independence in
areas of self care and mobility
 Dependent on quality and intensity of
therapy and extent of lesion
 Dependent on patient’s motivation
 Modifiable by interventions

6. Neurological Recovery
 Neurological recovery
◦ Early recovery (Local Processes)
◦ Late recovery (Neuroplasticity)
modification in structural and functional
organization
 Functional recovery
◦ Recovery in everyday function with adaptation
and training in presence/ absence of natural
neurologic recovery
◦ Dependent on quality ,intensity of therapy &
patient’s motivation

7. Early recovery ( Local
processes )
1.Resolution of post stroke edema
2.Reperfusion of ischemic penumbra
3.Resorption of local toxins
4.Recovery of partially damaged ischemic
neurons

8. Late recovery ( Neuroplasticity )
◦ Ability of nervous system to modify
structural and functional organisation
1.Collateral sprouting of new synaptic
connections
2.Unmasking of previously latent
functional pathways
3.Reversibility from diaschisis

9. Motor Rehabilitation
 Reacquisition of previously learned
movement & skills that are lost due to
pathology or sensory, motor or cognitive
impairment.
 Stroke rehabilitation requires a sustained
and coordinated effort from a large team.
 Communication and coordination among
these team members are of paramount
importance .

10. Principles of Stroke
Rehabilitation
motor learning induces
 Dendrite sprouting,
 New synapse formation,
 Alterations in existing synapses,
 Neurochemical production

11. Principles of Stroke
Rehabilitation…
Motor learning is known to be better if the
practice method is
 Meaningful,
 Repetitive,
 Intensive
 Task-specific
 Enriched environment

12. Early Mobilisation
 If condition stable – To start active mobilisation
within 24-48 hours
 Physiologically sound changes in bed position &
ROM exercise.
 Specific tasks ( sitting up, turning from side to
side ) & Self care activities ( feeding, grooming,
dressing )
 Tolerance for therapy affected by stroke
severity, medical stability, mental status, cardiac
instability & level of Consciousness.

13. Early Mobilisation…
 Early mobilisation reduces
complications and enhances functional
recovery (Level 1)
 Strong positive psychological benefit
 High-dose, very early mobilization
within 24 hours of stroke onset can
reduce the odds of a favorable outcome
at 3 months and is not recommended.

14. Gait training
 Initial gait training between parallel bars
then outside bars with aids & then without
aids
 In all direction & turning
 Foot clearance
– Orthoses & FES
 PBWSTT with higher speed improve
overall locomotor activity & over ground
speed

15. Improving Trunk Control
 Trunk forms a foundation for any posture
& movement.
 Post hemiparesis - loss of selective
muscle activity in trunk & tone .
 Rx focus on
-Trunk rotation, side flexion .
-Combination of movement
-Balance reaction[Anticipatory &
Reactive]
-Functional Activity

16. Improve UE Function
• Relearning of movement pattern &
retraining of missing component
• Upper body initiated wt shift
pattern[reaching & picking object]
• UL weight bearing & Dynamic
stabilization exercise

17. Improve UE Function…
• Functional movement & Combination
movement.
• Power production – Throwing
• Fine motor function- Object
Manipulation
• Adjuncts – Orthoses, CIMT, NMES,
VR, Robotics

18. Improve LE function
 Strengthening muscles in appropriate
pattern & Functional pattern.
 Training for posterior weight shift,
Anterior weight shift & Lateral weight
shift (sitting).
 Co-ordinated combination movement
 Power production [Kicking]
 Cycling & treadmill training

19. Spasticity
 Proper positioning of limb
 Passive ranging and stretching
 Functional electrical stimulation
 Pharmacological ( baclofen,
clonazepam, dantrolene)
 Alcohol/phenol neurolysis
 IM botox
 Surgical options eg. Intrathecal
baclofen pumps, tendon release

20. Current Treatment Methods
 Constraint-induced movement therapy
(CIMT),
 Body weight-supported treadmill training
(BWSTT),
 Robotic training,
 Transcutaneous neuromuscular electrical
stimulation,
 Noninvasive brain stimulation (NIBS),
 Mirror therapy
 Virtual reality (VR) training,
 Brain-computer interface (BCI).
 SSRI

21. Mirror Therapy and Imagery
 There is increasing experimental evidence that
some motor neural structures are recruited not
only when actions are actually executed but
also when the actions of another person are
simply observed or a movement is imagined.
 This form of practice is routinely used by
athletes and dancers before a performance to
reactivate in working memory the
representation of a motor memory
 The neurophysiological basis for this
recruitment is associated with “mirror neuron
system”

22.  According to the
mirror neuron
paradigm, action
observation appears
to activate the motor
system similar to
execution by
generating an internal
representation of
action that can be
targeted for motor

23.  Studies evaluating the benefits of adding
MT to routine stroke rehabilitation have
generally demonstrated statistically
significant improvements in motor and
functional outcomes although
interpretation of these studies is limited
by small sample sizes
 Future studies will hopefully clarify the
optimal timing, dose, frequency, and
duration of MT as well as which patient
populations respond best to treatment

24. CIMT
 The underlying concept of CIMT is that
restricting the use of the unaffected
upper extremity by a mitt or sling will
force an individual to use the affected
limb to complete task based activities,
affecting neuroplastic change and
improving upper extremity function over
time.
 The aim of CIMT is to overcome what is
theorized as “learned nonuse” of the
paretic limb

25. Aerobic exercises

26. CIMT
During treatment,
the patient wears a
mitt or constraint
on their intact limb,
and the impaired
limb is used for
tasks during
therapy and daily
activities

27. CIMT…
 The typical intervention consists of
restricting the unaffected limb for 90%
of waking hours for 14 days with 6
hours of therapy for 10 of those days.
The inclusion criteria for CIMT –
 The ability to actively extend the wrist,
thumb, and fingers
 Absence of cognitive impairment,
excessive spasticity, or impaired
balance

28. CIMT…
 studies evaluating the effects of CIMT
on upper extremity recovery in
poststroke patients have demonstrated
significant improvements in motor and
functional outcomes, although there
have been mixed results.
 in the acute stage of stroke, high-
intensity CIMT results in less
improvement than low-intensity CIMT

29. Selective Serotonin Reuptake
Inhibitor Medications
 A Cochrane Review published in 2012
evaluating 52 clinical trials found
significant benefits of SSRI
medications in reducing disability and
dependency as well as on
neurological deficit depression, and
anxiety.
 Risks and side effects of treatment
with SSRI, including the increased risk
of bleeding events, will need to be
noted and considered.

30. Noninvasive Brain Stimulation
 Noninvasive brain stimulation involves
the application of weak electric or
magnetic fields to the brain via the
surface of the scalp with the goal of
changing or normalizing brain activity.
 Noninvasive brain stimulation modulates
brain excitability and functional plasticity
with relative safety and facilitates motor
learning when combined with a motor
task

31. Noninvasive Brain
Stimulation…
2 most common forms are
 Transcranial magnetic stimulation
(TMS)
 Transcranial direct current stimulation
(tdcs)
 Neither modality is FDA approved in
stroke rehabilitation, but both are
currently being studied under off label
research purposes.

32. (A) Transcranial magnetic stimulation (TMS) of the brain
using a figure-of-8 coil.
(B) B, Transcranial direct current stimulation (tDCS) of
the brain with the active electrode (red wire, anode)
placed over the primary motor cortex and the
reference electrode (black wire, cathode) placed over
the contralateral supraorbital region.

33. Schematic representation of noninvasive brain
stimulation techniques for facilitating motor recovery
after stroke-
The aim of these techniques is to upregulate (↑) cortical
excitability of the lesioned hemisphere or to downregulate
(↓) cortical excitability of the contralateral nonlesioned
hemisphere.

34. NIBS…
 Studies have explored the efficacy of
NIBS for improving motor recovery
after stroke .
 A metaanalysis of 50 randomized
clinical trials and 1282 patients with
stroke found that both TMS and tDCS
were effective in improving motor
outcomes after stroke

35. NIBS…
Although the results from several smallscale
clinical trials appear promising and
encouraging, the role of NIBS in stroke
rehabilitation remains unclear for a variety
of reasons
 dearth of largescale clinical studies with
adequate longterm followup of patients with
stroke.
 the observed improvements are of modest
clinical significance with questionable effect

36. NIBS…
 The optimal way of combining NIBS with
physical rehabilitation (ie, whether TMS
or tDCS should precede, follow, or be
combined with therapy) is still unclear.
 The uncertainty about the timing of
NIBS
 Finally, TMS or tDCS induced directional
modulation of motor cortical excitability is
known to be variable both within and
between patients

37. BWSTT
 The addition of partial body weight support to
treadmill training (BWSTT) has been tested in
patients with stroke, SCI, Parkinson, MS, and
cerebral palsy.
 Subjects wear a chest harness that is
attached to an overhead lift. The amount of
weight borne by the lower extremities is
adjusted to optimize the stance and swing
phases of gait.
 One or more therapists may manually assist
the lower extremities and pelvis during step
training to optimize the step pattern.

38. BWSTT…
 BWSTT allows repetitive practice guided
by the verbal and physical cues of the
therapist to improve components of the
step cycle.
 The Locomotor Experience Applied Post
Stroke (LEAPS) Trial randomized 400
subjects. It compared usual care to
BWSTT.
 Improvements were significant for
supervised home-based exercise and for
BWSTT compared to usual care when
started at 2 months.

40. Functional Neuromuscular
Stimulation
 Functional neuromuscular stimulation
systems activate one or more muscle
groups synchronously or sequentially to
enable single-joint and multijoint
movements.
 Surface and intramuscular electrical
stimulation systems have become more
widely available in the past 5 years, but
despite extensive study and commercial
development, they have not come into
sustained use.

41. Functional Neuromuscular
Stimulation…
 The first commercial surface electrode-driven
device for grasping is the Ness System, which
has found some use in quadriplegic patients
with at least C5 intact and in hemiplegic patients
with poor hand function .
 Electrodes attached to a molded forearm
orthosis that reaches across the wrist stimulate
the wrist and finger flexors and extensors in
synchrony.
 The external control unit operates from a button
managed by the patient for the level of output

42. •The hemiparetic right
arm is assisted by an
orthosis with functional
neuromuscular
stimulation that helps
dorsiflex the wrist and
produce a palmar
grasp or finger pinch
(NESS by Bioness,
Inc.).
•Practical utility
depends on the ability
to lift and extend the
proximal arm

43. Functional Neuromuscular
Stimulation…
 Peroneal nerve stimulation to aid foot
dorsiflexion to clear the foot during the
swing phase can increase step length
and walking speed in hemiparetic
persons.
 A growing number of commercial
devices are available that use an
accelerometer to switch on the below-
the-knee stimulus.

45. VR training
 VR is a computer-based technology
that engages users in multisensory
simulated environments, including
real-time feedback (e.g., visual,
auditory, and tactile feedback),
allowing users to experience
simulated real-world objects and
events .
 May be nonimmersive to fully

46. VR training…
 Immersive VR systems use large-
screen projections, head-mounted
displays, cave systems, or
videocapture systems to immerse the
user in a virtual environment
 In contrast, nonimmersive VR systems
simply use a computer screen to
simulate an experience with or without
interface devices.

47. VR training…
 VR exercise provide repetitive,
intensive, and task-specific training
which can promote neural plasticity
that produce motor function
improvements after stroke.
 Several studies have shown that the
use of immersive VR results in
practice-dependent enhancement of
the affected arm by facilitating cortical
reorganization

48. VR training…
 Small clinical trials also have revealed
encouraging results for cognitive
rehabilitation assessment and for the
treatment of attention and spatial
memory deficits and apraxia.

49. Mechanical and Robotic-
Assistive Devices
 Electromechanical robotic devices
have been developed to provide
assistance for intensity and
reproducibility of practice.
 Portable exoskeleton devices work in
concert with the paretic arm and leg
movements .

50. Neural Prostheses and Brain–
Computer Interfaces
 To aid the highly disabled
persons(ALS, locked-in syndrome
after stroke or trauma, MS, cerebral
palsy, or muscular dystrophy ), to
manage their surroundings and
communicate, a variety of brain-
computer interfaces (BCI) have been
developed and tested (Hochberg et
al., 2012).

51. BCI
 The devices use surface and intracortical neural
signals picked up by microelectrode from
defined regions of the brain
 Selected signals are digitized and processed by
algorithms to extract specific features.
 A translation algorithm converts the particular
electrophysiological features chosen to simple
commands to a device such as a word
processor or keyboard, a website, or an upper-
extremity neuroprosthesis.
 (SIGNAL DECODING COMMAND)

52. BCI…
 The error rate is often in the range of
10% to 20%.
 Major improvements in signal
processing and interfaces should offer
greater utility for paralyzed patients.

53. Mobile Health and Wireless
Sensing Devices
 Smartphones, Web-based tele-
rehabilitation, and wearable
accelerometers with pattern-recognition
algorithms that can calculate the type,
quantity and quality of movements in the
community are now available.
 These technologies may improve
compliance with exercise and skills
learning via continuous monitoring of gait
or use of an upper extremity.
 Simpler devices that serve as step
monitors, worn on the wrist, trunk or on

54. Take home message
 Team Approach
 Evidence Based Practice
 Early Mobilisation
 Aerobic Training
 Neuroplasticity & Motor learning principle

55. Thank you

56. References
 Bradley’s Neurology In Clinical Practice 7th
Edition.
 Emerging Treatments for Motor Rehabilitation
After Stroke; Edward S. Claflin, MD, Chandramouli
Krishnan, PhD, PT, and Sandeep P. Khot, MD
 Promoting Neuroplasticity for Motor Rehabilitation
After Stroke: Considering the Effects of Aerobic
exercise and Genetic Variation on BrainDerived
Neurotrophic Factor; Cameron S. Mang, Kristin L.
Campbell, Colin J.D. Ross, Lara A. Boyd
 Rehabilitation with Poststroke Motor Recovery: A
Review with a Focus on Neural Plasticity ;
Naoyuki Takeuchi and Shin-Ichi Izumi